The role of patient held beliefs about injury and recovery in the development of late whiplash syndrome following an acute whiplash injury

This thesis has investigated the role of patient held beliefs about injury and recovery in the development of late whiplash syndrome (LWS) following an acute whiplash injury. Beliefs about injury and recovery have the potential to influence outcome. These beliefs are potentially modifiable through physiotherapy management and gaining greater understanding into how they influence outcome can potentially improve physiotherapy management of acute whiplash injuries. Mixed methods were used to investigate the role of these beliefs in the development of LWS. Following a systematic literature review, a prospective cohort study was carried out to identify risk factors for LWS as well as Neck Disability Index Scores and participant perceived improvement at follow up. This was complemented by a qualitative study designed to gain greater insight into the patient’s experience of recovering from a whiplash injury. Patients’ expectations of outcome were found to influence the development of LWS, in particular, their expectations of time to recovery. Patients’ expectations of treatment benefit were found to influence outcome to a lesser degree. The patients’ belief about their ability to cope with their neck problem (self-efficacy) was shown to influence outcome in the short term but not long term follow up. The use of passive coping strategies may moderate the influence of these types of beliefs. The qualitative study highlighted the importance of realistic expectations, the value of reassurance from health professionals and how the patient’s understanding of pain are important in identifying potential barriers to recovery. This thesis has also presented detailed information about the clinical presentation of individuals who have sustained a whiplash injury and explored patterns of recovery amongst individuals. This will help clinicians to understand the nature of whiplash injuries and how they impact on patients which has the potential to improve patient management

The role of patient held beliefs about injury and recovery in the development of late whiplash syndrome following an acute whiplash injury

This thesis has investigated the role of patient held beliefs about injury and recovery in the development of late whiplash syndrome (LWS) following an acute whiplash injury. Beliefs about injury and recovery have the potential to influence outcome. These beliefs are potentially modifiable through physiotherapy management and gaining greater understanding into how they influence outcome can potentially improve physiotherapy management of acute whiplash injuries. Mixed methods were used to investigate the role of these beliefs in the development of LWS. Following a systematic literature review, a prospective cohort study was carried out to identify risk factors for LWS as well as Neck Disability Index Scores and participant perceived improvement at follow up. This was complemented by a qualitative study designed to gain greater insight into the patient’s experience of recovering from a whiplash injury. Patients’ expectations of outcome were found to influence the development of LWS, in particular, their expectations of time to recovery. Patients’ expectations of treatment benefit were found to influence outcome to a lesser degree. The patients’ belief about their ability to cope with their neck problem (self-efficacy) was shown to influence outcome in the short term but not long term follow up. The use of passive coping strategies may moderate the influence of these types of beliefs. The qualitative study highlighted the importance of realistic expectations, the value of reassurance from health professionals and how the patient’s understanding of pain are important in identifying potential barriers to recovery. This thesis has also presented detailed information about the clinical presentation of individuals who have sustained a whiplash injury and explored patterns of recovery amongst individuals. This will help clinicians to understand the nature of whiplash injuries and how they impact on patients which has the potential to improve patient management.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Does a monetary incentive improve the response to a postal questionnaire in a randomised controlled trial? : the MINT incentive study

Background: Sending a monetary incentive with postal questionnaires has been found to improve the proportion of responders, in research in non-healthcare settings. However, there is little research on use of incentives to improve follow-up rates in clinical trials, and existing studies are inconclusive. We conducted a randomised trial among participants in the Managing Injuries of the Neck Trial (MINT) to investigate the effects on the proportion of questionnaires returned and overall non-response of sending a £5 gift voucher with a follow-up questionnaire. Methods: Participants in MINT were randomised to receive either: (a) a £5 gift voucher (incentive group) or (b) no gift voucher (no incentive group), with their 4 month or 8 month follow-up questionnaire. We recorded, for each group, the number of questionnaires returned, the number returned without any chasing from the study office, the overall number of non-responders (after all chasing efforts by the study office), and the costs of following up each group. Results: 2144 participants were randomised, 1070 to the incentive group and 1074 to the no incentive group. The proportion of questionnaires returned (RR 1.10 (95% CI 1.05, 1.16)) and the proportion returned without chasing (RR 1.14 (95% CI 1.05, 1.24) were higher in the incentive group, and the overall non-response rate was lower (RR 0.68 (95% CI 0.53, 0.87)). Adjustment for injury severity and hospital of recruitment to MINT made no difference to these results, and there were no differences in results between the 4-month and 8-month follow up questionnaires. Analysis of costs suggested a cost of £67.29 per additional questionnaire returned. Conclusion: Monetary incentives may be an effective way to increase the proportion of postal questionnaires returned and minimise loss to follow-up in clinical trials

A longitudinal, qualitative study exploring sustained adherence to a hand exercise programme for Rheumatoid Arthritis evaluated in the SARAH Trial

Purpose: This study explores the experience of participants taking part in a hand exercise programme for people with rheumatoid arthritis with a focus on adherence. The exercise programme was tested in a randomised controlled trial. This parallel qualitative study will inform future implementation into clinical practice. Method: Twenty-seven semi-structured interviews from 14 participants were undertaken at 2 time points (4 and 12 months after randomisation). We collected data of participants’ experiences over time. This was guided by an interview schedule. Interview data were analysed using interpretative phenomenological analysis which is informed by phenomenological and hermeneutic theory. We recruited participants from National Health Service rheumatology and therapy departments. Results: At 4 months, 11/14 participants reported continuing with the exercises. By 12 months, 7/13 participants still reported exercising. The ability to establish a routine determined whether participants adhered to the exercise programme. This was sometimes influenced by practical issues. We also identified facilitators and barriers to regular exercise in the themes of – the therapeutic encounter, perceived benefit of exercises, attitude of mind, confidence and unpredictability. Conclusions: Establishing a routine was an important step towards participants being able to exercise independently. Therapists provided participants with skills to continue to exercise while dealing with changes in symptoms and schedules. Potential barriers to long term exercise adherence need to be taken into account and addressed for successful implementation of this programme

A national survey of clinical practice for the management of whiplash-associated disorders in UK emergency departments

Objective: To undertake a national survey to determine current practice for the management of whiplash injuries in UK emergency departments (ED). Methods: Postal questionnaire survey. 316 lead consultants from all UK ED with annual new attendances of over 50 000 people were asked to indicate the use of a range of treatments and the frequency with which these treatments were used. Samples of written advice were requested and content analysis was conducted and compared with survey responses. Results: The response rate was 79% (251/316). The intervention most frequently used was verbal advice to exercise, reported by 84% of respondents for most or all cases, and advice against the use of a collar (83%). Other treatments reported as being used frequently were written advice and anti-inflammatory medication. 106 consultants (42%) provided a sample of written materials. Reference to expected recovery and encouragement for early return to activities were included in less than 6%. Nearly 50% of written materials contained information on how to use a soft collar and 61% contained information on solicitors and pursuing a personal injury claim. There were important differences between reported verbal behaviours and written advice. Conclusion: Verbal advice is the primary method for managing whiplash injuries in ED and is usually supplemented by written advice. Within individual hospitals there is a lack of consistency between verbal and written advice. The promotion of personal injury claims is a common feature of written advice. Research is required to develop effective and consistent models of advice

Using mixed methods evaluation to assess the feasibility of online clinical training in evidence based interventions : a case study of cognitive behavioural treatment for low back pain

Background: Cognitive behavioural (CB) approaches are effective in the management of non-specific low back pain (LBP). We developed the CB Back Skills Training programme (BeST) and previously provided evidence of clinical and cost effectiveness in a large pragmatic trial. However, practice change is challenged by a lack of treatment guidance and training for clinicians. We aimed to explore the feasibility and acceptability of an online programme (iBeST) for providing training in a CB approach. Methods: This mixed methods study comprised an individually randomised controlled trial of 35 physiotherapists and an interview study of 8 physiotherapists. Participants were recruited from 8 National Health Service departments in England and allocated by a computer generated randomisation list to receive iBeST (n = 16) or a face-to-face workshop (n = 19). Knowledge (of a CB approach), clinical skills (unblinded assessment of CB skills in practice), self-efficacy (reported confidence in using new skills), attitudes (towards LBP management), and satisfaction were assessed after training. Engagement with iBeST was assessed with user analytics. Interviews explored acceptability and experiences with iBeST. Data sets were analysed independently and jointly interpreted. Results: Fifteen (94 %) participants in the iBeST group and 16 (84 %) participants in the workshop group provided data immediately after training. We observed similar scores on knowledge (MD (95 % CI): 0.97 (−1.33, 3.26)), and self-efficacy to deliver the majority of the programme (MD (95 % CI) 0.25 (−1.7; 0.7)). However, the workshop group showed greater reduction in biomedical attitudes to LBP management (MD (95 % CI): −7.43 (−10.97, −3.89)). Clinical skills were assessed in 5 (33 %) iBeST participants and 7 (38 %) workshop participants within 6 months of training and were similar between groups (MD (95 % CI): 0.17(−0.2; 0.54)). Interviews highlighted that while initially sceptical, participants found iBeST acceptable. A number of strategies were identified to enhance future versions of iBeST such as including more skills practice. Conclusions: Combined quantitative and qualitative data indicated that online training was an acceptable and promising method for providing training in an evidence based complex intervention. With future enhancement, the potential reach of this training method may facilitate evidence-based practice through large scale upskilling of the workforce

Economic and health-related quality of life outcomes of whiplash associated disorders

STUDY DESIGN: This study examines the links between severity of whiplash associated disorder and costs and health outcomes OBJECTIVE.: The aim of this study was to estimate the economic costs and health state utilities associated with disability levels and recovery trajectories following acute whiplash injury. SUMMARY OF BACKGROUND DATA: Data used were from the Managing Injuries of the Neck Trial, which collected information on 3,851 people over a 12 month period following acute whiplash injury. METHODS: Effects of whiplash associated disorder severity on economic costs (measured from a societal perspective and separately from a health and personal social services perspective) were estimated using two-part regression models, comprising probability of incurring a cost and the total cost, given one was incurred. Effects on health state utilities (measured using the EQ-5D and SF-6D) were estimated using ordinary least squares regression, and two-part models as for costs. RESULTS: There was a direct relationship between severity of disability following acute whiplash injury and economic costs. Between baseline and 4 months, average societal costs for those with no disability were £99.55 (UK£, 2009 prices), increasing to £668.53 for those with complete disability. Average societal costs for the whole sample were £234.15 over the first 4 months, decreasing to £127.51 between 8 and 12 months. Conversely, utility scores decreased with increased disability. The average EQ-5D utility score was 0.934 at 4 months for those with no disability, decreasing to 0.033 for those with complete disability. The average EQ-5D utility score for the whole sample increased from 0.587 immediately post-injury to 0.817 at 12 months. Relative costs and disutilities generated by the multivariate models are also presented by disability level and recovery trajectory. CONCLUSIONS: These results provide estimates of the costs and health state utilities associated with disability levels and recovery trajectories following acute whiplash injury. They can be used to inform estimates of the cost-effectiveness of interventions targeting whiplash associated disorders

Managing Injuries of the Neck Trial (MINT) : design of a randomised controlled trial of treatments for whiplash associated disorders

Background: A substantial proportion of patients with whiplash injuries develop chronic symptoms. However, the best treatment of acute injuries to prevent long-term problems is uncertain. A stepped care treatment pathway has been proposed, in which patients are given advice and education at their initial visit to the emergency department (ED), followed by review at three weeks and physiotherapy for those with persisting symptoms. MINT is a two-stage randomised controlled trial to evaluate two components of such a pathway: 1. use of The Whiplash Book versus usual advice when patients first attend the emergency department; 2. referral to physiotherapy versus reinforcement of advice for patients with continuing symptoms at three weeks. Methods: Evaluation of the Whiplash Book versus usual advice uses a cluster randomised design in emergency departments of eight NHS Trusts. Eligible patients are identified by clinicians in participating emergency departments and are sent a study questionnaire within a week of their ED attendance. Three thousand participants will be included. Patients with persisting symptoms three weeks after their ED attendance are eligible to join an individually randomised study of physiotherapy versus reinforcement of the advice given in ED. Six hundred participants will be randomised. Follow-up is at 4, 8 and 12 months after their ED attendance. Primary outcome is the Neck Disability Index (NDI), and secondary outcomes include quality of life and time to return to work and normal activities. An economic evaluation is being carried out. Conclusion: This paper describes the protocol and operational aspects of a complex intervention trial based in NHS emergency and physiotherapy departments, evaluating two components of a stepped-care approach to the treatment of whiplash injuries. The trial uses two randomisations, with the first stage being cluster randomised and the second individually randomised

Acid-Triggered O−O Bond Heterolysis of a Nonheme FeIII (OOH) Species for the Stereospecific Hydroxylation of Strong C−H Bonds

A novel hydroperoxoiron(III) species [FeIII(OOH)(MeCN)(PyNMe3)]2+ (3) has been generated by reaction of its ferrous precursor [FeII(CF3SO3)2(PyNMe3)] (1) with hydrogen peroxide at low temperatures. This species has been characterized by several spectroscopic techniques and cryospray mass spectrometry. Similar to most of the previously described low‐spin hydroperoxoiron(III) compounds, 3 behaves as a sluggish oxidant and it is not kinetically competent for breaking weak C−H bonds. However, triflic acid addition to 3 causes its transformation into a much more reactive compound towards organic substrates that is capable of oxidizing unactivated C−H bonds with high stereospecificity. Stopped‐flow kinetic analyses and theoretical studies provide a rationale for the observed chemistry, a triflic‐acid‐assisted heterolytic cleavage of the O−O bond to form a putative strongly oxidizing oxoiron(V) species. This mechanism is reminiscent to that observed in heme systems, where protonation of the hydroperoxo intermediate leads to the formation of the high‐valent [(Porph.)FeIV(O)] (Compound I)